=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558360826
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN EARL DAVIS D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 WINDSOR ST
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77340-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-291-3345
-----------------------------------------------------
Fax | 936-291-9866
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 WINDSOR ST
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77340-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-291-3345
-----------------------------------------------------
Fax | 936-291-9866
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 10039
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------